Conditional Cash Transfer Intervention Research Articles

Implementation of the Afya conditional cash transfer intervention to retain women in the continuum of care: a mixed-methods process evaluation

ObjectivesWe report the results of a mixed-methods process evaluation that aimed to provide insight on the Afya conditional cash transfer (CCT) intervention fidelity and acceptability.Intervention, setting and participantsThe Afya CCT...

The effect of conditional cash transfers on the control of neglected tropical disease: a systematic review

Neglected tropical diseases (NTDs) are diseases of poverty and affect 1·5 billion people globally. Conditional cash transfer (CCTs) programmes alleviate poverty in many countries, potentially contributing to improved NTD outcomes. This systematic review examines the relationship between CCTs and screening, incidence, or treatment outcomes of NTDs. In this systematic review we searched MEDLINE, Embase, Lilacs, EconLit, Global Health, and grey literature websites on Sept 17, 2020, with no date or language restrictions. Controlled quantitative studies including randomised controlled trials (RCTs) and observational studies evaluating CCT interventions in low-income and middle-income countries were included. Any outcome measures related to WHO's 20 diseases classified as NTDs were included. Studies from high-income countries were excluded. Two authors (AA and TH) extracted data from published studies and appraised risk of biases using the Risk of Bias in Non-Randomised Studies of Interventions and Risk of Bias 2 tools. Results were analysed narratively. This study is registered with PROSPERO, CRD42020202480. From the search, 5165 records were identified; of these, 11 studies were eligible for inclusion covering four CCTs in Brazil, the Philippines, Mexico, and Zambia. Most studies were either RCTs or quasi-experimental studies and ten were assessed to be of moderate quality. Seven studies reported improved NTD outcomes associated with CCTs, in particular, reduced incidence of leprosy and increased uptake of deworming treatments. There was some evidence of greater benefit of CCTS in lower socioeconomic groups but subgroup analysis was scarce. Methodological weaknesses include self-reported outcomes, missing data, improper randomisation, and differences between CCT and comparator populations in observational studies. The available evidence is currently limited, covering a small proportion of CCTs and NTDs. CCTs can be associated with improved NTD outcomes, and could be driven by both improvements in living standards from cash benefits and direct health effects from conditionalities related to health-care use. This evidence adds to the knowledge of health-improving effects from CCTs in poor and vulnerable populations. None.

Role of temporal discounting in a conditional cash transfer (CCT) intervention to improve engagement in the prevention of mother-to-child transmission (PMTCT) cascade

BackgroundTemporal discounting, the tendency of individuals to discount future costs and benefits relative to the present, is often associated with greater engagement in risky behaviors. Incentives such as conditional cash transfers (CCTs) have the potential to counter the effects of high discount rates on health behaviors.MethodsWith data from a randomized trial of a CCT intervention among 434 HIV-positive pregnant women in the Democratic Republic of Congo, we used binomial models to assess interactions between discount rates (measured using a delay-discounting task) and the intervention. The analysis focused on two outcomes: 1) retention in HIV care, and 2) uptake of prevention of mother-to-child transmission (PMTCT) services.ResultsThe effect of high discount rates on retention was small, and we did not observe evidence of interaction between high discount rates and CCT on retention. However, our findings suggest that CCT may mitigate the negative effect of high discount rates on uptake of PMTCT services (interaction contrast (IC): 0.18, 95% CI: − 0.09, 0.44).ConclusionsOur findings provide evidence to support the continued use of small, frequent incentives, to motivate improved uptake of PMTCT services, especially among women exhibiting high rates of temporal discounting.Trial registrationClinicaltrials.gov number NCT01838005, April 23, 2013.

The Impact of a Conditional Cash Transfer on Multidimensional Deprivation of Young Women: Evidence from South Africa\u2019s HTPN 068

Despite the growing popularity of multidimensional poverty measurement and analysis, its use to measure the impact of social protection programs remains scarce. Using primary data collected for the evaluation of HIV Prevention Trials Network (HPTN) 068, a randomized, conditional cash transfer intervention for young girls in South Africa that ran from 2011 to 2015, we construct an individual-level measure of multidimensional poverty, a major departure from standard indices that use the household as the unit of analysis. We construct our measure by aggregating multiple deprivation indicators across six dimensions and using a system of nested weights where each domain is weighted equally. Our findings show that the cash transfer consistently reduces deprivations among girls, in particular through the domains of economic agency, violence, and relationships. These results show how social protection interventions can improve the lives of young women beyond single domains and demonstrate the potential for social protection to simultaneously address multiple targets of the SDGs.

Conditional cash transfers to prevent mother-to-child transmission in low facility-delivery settings: evidence from a randomised controlled trial in Nigeria

BackgroundNigeria suffers from the highest burden of mother-to-child transmission worldwide. To increase retention in care and prevention programmes, we piloted and evaluated a conditional cash transfer (CCT) programme for preventing mother-to-child transmission (PMTCT) in Akwa Ibom, Nigeria.MethodsIn a randomised controlled trial, pregnant women testing positive for HIV during antenatal care registration at three public hospitals were randomised to one of two study arms: (1) offered enrolment into the CCT programme or (2) continue in standard care for (PMTCT). In the CCT programme, women could receive a compensation package totaling 33,300 Naira (~US$114) for enroling, delivering at the facility, and obtaining a newborn early infant diagnosis (EID) test. The intent-to-treat (ITT) and per protocol (PP) effects of the programme on the primary outcomes of facility delivery and EID testing and on the secondary outcome of nevirapine administration were estimated with logistic regressions.ResultsFrom August 1, 2015 to April 19, 2017, 554 pregnant women tested positive for HIV; 273 were randomised to standard care and 281 were offered enrolment into the CCT intervention. Women offered the CCT programme were more likely to give birth at the facility (n = 109/263; 41.4%) compared to women in standard care (n = 80/254; 31.5%), an absolute difference of 9.9% (OR = 1.54, 95% CI: 1.07–2.21, p = 0.019). For EID testing there was an absolute difference of 12.8% between those offered the CCT intervention (n = 69/263; 26.2%) and those in standard care (n = 34/254; 13.4%; OR = 2.30, 95% CI 1.46–3.62, p = 0.000). PP results show larger differences for both facility deliveries (16.7% absolute difference; OR = 2.02, 95% CI 1.38–2.98, p = 0.000) and EID testing (18.9% absolute difference; OR = 3.09, 95% CI 1.93–4.94, p = 0.000) among intervention enrolees. Over 86% of the facility-delivered newborns received nevirapine, and ITT and PP estimates were similar to those for facility deliveries.ConclusionsResults show that CCTs improved the likelihood of HIV-positive women giving birth at a facility, of nevirapine being administered to their newborn, and of undergoing EID testing in Akwa Ibom, Nigeria. Effects are especially large among those who agreed to participate in the CCT intervention.Trial registrationClinicalTrials.gov NCT02447159, May 18, 2015.

Cluster randomized stepped-wedge trial of a multi-level HIV prevention intervention to decrease amphetamine-type stimulants and sexual risk in Cambodian female entertainment and sex workers

BackgroundHIV prevention for female entertainment and sex workers (FESW) may be optimized by addressing individual and structural risks. We examined the impact of a sequentially delivered intervention to decrease sexual risk, amphetamine-type stimulant (ATS) use, and improve economic well-being in Cambodian FESW. MethodsA cluster randomized stepped-wedge trial was conducted in 10 Cambodian provinces to test multi-level intervention in high risk FESW. After baseline screening in 1198 women, those screening positive for ATS use disorder were allocated to a 12-week conditional cash transfer intervention followed by a 4-week cognitive-behavioural aftercare group (CCT + AC). At six months, ATS abstinent participants were offered a microenterprise (ME) opportunity. Co-primary outcomes assessed in 600 FESW at each 6-, 12- and 18-month follow-up assessments, included: 1) number of sexual partners (past three months); and 2) ATS urine toxicology positive (Tox+) results. Secondary outcomes included indicators of economic well-being. ResultsRelative to baseline, FESW reported fewer sexual partners at all follow-up assessments with a significant 50% decrease at 12-months (Adjusted Rate Ratio [ARR] = 0.50; 95%CI: 0.25, 0.95). Women had 60% lower odds of being ATS Tox+ (Adjusted Odds Ratio [AOR] = 0.40; 95%CI: 0.25, 0.65) at 6-months, and continued but non-significant reductions at 12- and 18-months. Improvements in economic well-being indicators were observed at 12- and 18-months. ConclusionsFindings support the robust effectiveness of the sequentially delivered CCT + AC and ME interventions for boosting HIV prevention for Cambodian FESW. Further research is needed to inform the scale up and improve durability of this comprehensive approach with FESW in Southeast Asia.

A randomized trial of cash incentives for sexual behavior change among female sex workers in Dar es Salaam.

Female sex workers (FSW) across the world are at high risk for HIV infection and much work is needed to scale up HIV prevention programs among this group. Conditional cash transfer (CCT) programs have been used successfully in recent years to encourage behavior change. We report the results of a CCT intervention among FSW in Tanzania. We conducted a randomized controlled trial (N = 100) of a CCT intervention among FSW in Dar-es-Salaam, Tanzania in 2013. A respondent-driven sampling approach recruited women and randomized them into two groups based on the value of the cash incentive ($20 vs. $40 per visit). All women received testing for 2 curable sexually transmitted infections (STIs), trichomonas and syphilis, free treatment for those STIs and counseling. Women attended study visits at 0, 2 and 4 months and were tested for STIs and received counseling at each visit. Women testing negative for both STIs at the 2- and 4-month visits received a cash reward. Eighty-four women were retained in the study through all three visits. Participants reported significant reductions in the number of clients per week, and increases in the proportion of clients that they used condoms with over the course of the study. STI results showed decreases in prevalence from baseline to final study visit for syphilis and trichomonas. While this study was not powered to determine if the incentive resulted in statistically significant increases in condom use or decreases in STI prevalence, the results show the acceptability of the intervention, the feasibility of the recruitment methods, and the ability to retain FSW participants across multiple study visits. A follow-up randomized study with a larger number of participants is planned to test the efficacy of the intervention among high-risk populations of women engaging in transactional sex.

Effect of a Conditional Cash Transfer Program on Nutritional Knowledge and Food Practices among Caregivers of 3-5-Year-Old Left-Behind Children in the Rural Hunan Province.

Left-behind children (LBC) are a unique population in China, whose numbers have increased dramatically in recent years. Most caregivers of left-behind children (CLBC) are grandparents who lack knowledge about proper nutrition and food practice, putting LBC at greater risk for malnutrition. A cluster randomized controlled trial was carried to assess the effectiveness of the conditional cash transfer (CCT) program. Forty rural villages from Fenghuang County and Pingjiang County of Hunan province were selected. The villages were randomized into the intervention and control groups. In the intervention group, caregivers received a cash transfer conditional on bimonthly health education attendance, bringing LBC in for vaccinations, and on-time annual health checks. The control group received routine health services only. Two rounds of questionnaire surveys were conducted in March 2015 and July 2016. Questionnaires and in-person interviews were used to assess the changes in nutritional knowledge and food practices among CLBC. Among 447 valid subjects, CLBC in the intervention group were significantly more likely to correctly understand the importance of children’s height and weight measurements, food variety, inclusion of eggs and dairy in the diet, and anemia identification and prevention. Intervention group CLBC were also significantly more likely to prepare dairy products and eggs for their children. Generalized liner mixed model (GLMM) analysis showed that CLBC nutrition knowledge was improved significantly in the intervention group (adjusted p value = 0.01), and there were also positive changes in their food practice (adjusted p value = 0.047). This CCT intervention turned to be effective with respect to rural caregivers’ nutritional knowledge and food practice behavior. The findings from this project could be helpful for future health strategies targeting rural children, in particular the LBC group.

Women's Relationship Power Modifies the Effect of a Randomized Conditional Cash Transfer Intervention for Safer Sex in Tanzania.

This study tests whether women's relationship power modifies the effect of a conditional cash transfer (CCT) on STI risk. We analyzed 988 women enrolled in the RESPECT study in Tanzania, a yearlong, randomized-controlled trial testing the effectiveness of a CCT to reduce STI incidence. Women were randomized at the individual level to a no-cash control group, a low-cash, or a high-cash study arm. After one year, there was no main effect of study arm on risk of having an STI among women. However, in tests of heterogeneity, the effect of the CCT varied by a woman's relationship power (adjusted RRs of the interaction term for women with higher relationship power: RR 0.567 (95% CI 0.240-0.895) for high cash and RR 1.217 (95% CI 0.794-1.641) for low cash). Specifically, women with higher relationship power in the low cash transfer arm had an elevated risk of testing positive for an STI, whereas women with high relationship power in the high cash transfer arm had a decreased risk of testing positive for an STI.

Female sex workers use power over their day-to-day lives to meet the condition of a conditional cash transfer intervention to incentivize safe sex

Female Sex Workers are a core population in the HIV epidemic, and interventions such as conditional cash transfers (CCTs), effective in other health domains, are a promising new approach to reduce the spread of HIV. Here we investigate how a population of Tanzanian female sex workers, though constrained in many ways, experience and use their power in the context of a CCT intervention that incentivizes safe sex. We analyzed 20 qualitative in-depth interviews with female sex workers enrolled in a randomized-controlled CCT program, the RESPECT II pilot, and found that while such women have limited choices, they do have substantial power over their work logistics that they leveraged to meet the conditions of the CCT and receive the cash award. It was through these decisions over work logistics, such as reducing the number of workdays and clients, that the CCT intervention had its greatest impact on modifying female sex workers’ behavior.

Effectiveness of a conditional cash transfer programme on TB cure rate: a retrospective cohort study in Brazil

Despite the efforts of the National Tuberculosis Programme, TB cure rates in Brazil are sub-optimal. The End TB Strategy for post-2015 identifies conditional cash transfer interventions as powerful tools to improve TB control indicators, including TB cure rate. This study aims to inform the new policy by evaluating the role of the Bolsa Familia Programme (BFP), one of the largest conditional cash transfer programmes in the world, on TB cure rates in Brazil. We undertook a retrospective cohort study, based on an unprecedented record linkage of socioeconomic and health data, to compare cases of patients newly diagnosed with TB in 2010 receiving BFP cash benefits (n=5788) with those who did not (n=1467) during TB treatment. We used Poisson regression with robust variance to estimate the relative risks for TB cure adjusted for known confounders. The cure rate among patients exposed to BFP during TB treatment was 82.1% (4752/5788), 5.2% higher than among those not exposed. This was confirmed after controlling for TB type, diabetes mellitus, HIV status and other relevant clinical and socioeconomic covariates (RR=1.07, 95% CI 1.04 to 1.11 for cure rates among BFP beneficiaries). This association seemed higher for patients not under directly observed treatment (RR=1.11; 95% CI 1.05 to 1.16). Although further research is needed, this study suggests that conditional cash transfer programmes can contribute to improve TB cure rate in Brazil.

Behavioral interventions for Cambodian female entertainment and sex workers who use amphetamine-type stimulants.

Conditional cash transfer (CCT) and cognitive-behavioral treatments are evidence-based approaches to reduce stimulant use and sexual risk taking. We describe the adaptation and implementation of sequential behavioral interventions for Cambodian female entertainment and sex workers (FESW) who use amphetamine-type stimulants (ATS): (1) a 12-week CCT intervention; and (2) a 4-week cognitive-behavioral aftercare (AC) group. An ongoing cluster randomized stepped wedge trial in 10 Cambodian provinces is enrolling FESW with confirmed recent ATS use to examine the effectiveness of CCT+AC. In the first six provinces, 138 of the 183 eligible FESW (75%) enrolled in CCT and completed a median of 25 (interquartile range 9-32) of the 36 urine screening visits. Of the 84 participants who were eligible for AC, 79 completed at least one session (94%) and 57 completed three or more sessions (68%). Culturally tailored behavioral interventions to reduce ATS use and optimize HIV prevention are feasible in resource-limited settings.

Qualitative research and implementation science: Informing the acceptability and implementation of a trial of a conditional cash transfer intervention designed to reduce drug use and HIV risk.

HIV risk remains high among Cambodian female entertainment and sex workers, driven by amphetamine-type substance use and sexual risk. Conditional cash transfer is an evidence-based approach to reduce stimulant use and optimize HIV/AIDS prevention, but questions remain regarding implementation in resource-limited settings. We conducted formative qualitative research to enhance acceptability of a conditional cash transfer intervention aimed at reducing amphetamine-type substance use and HIV risk among female entertainment/sex workers and inform implementation as part of a large cluster randomized trial. We conducted in-depth interviews with 30 female entertainment/sex workers. Interviews were digitally recorded and conducted and transcribed in Khmer. English transcripts were read for emerging themes and an initial coding scheme was developed. Data were coded using open and axial coding to clarify and consolidate initial themes. While most participants expressed enthusiasm for the intervention, financial and transportation issues emerged as key barriers to participation. The proposed incentive of USD$1 per screen was regarded as unacceptable and participants identified a need for transportation assistance. Participants also expressed concerns about directly observed urine specimen collection. Finally, while most participants found the 4-week aftercare program acceptable, the need for enjoyable as well as educational content was emphasized. Revisions to the protocol taking these data into account were made to optimize the acceptability of the intervention and the implementation of the trial. Findings identified key concerns and preferences that were taken into account in the final trial protocol. In particular, financial and transportation issues were identified as critical barriers to participation, with the potential to impact both intervention uptake and trial feasibility. Results demonstrate the value of formative qualitative research for clinical trial planning and implementation, particularly in settings where little is known about acceptability of interventions or willingness to participate.

Encouraging Savings Behavior through Conditional Cash Transfers: Lessons from Latin America

Savings, in the form of financial capital held in formal bank accounts, are an important factor in reducing poverty. They can stimulate financial inclusion of the poor, protect against unforeseen shocks, and fund long-term investments in human and economic development. However, the poor have limited options for formal savings. In recent years, governments around the world have begun to incorporate savings into their conditional cash transfer interventions. This paper focuses on such interventions by national and municipal governments in Latin America. While the evidence base is still too small to draw any firm conclusions about short-term benefits or long-term effectiveness, there have been positive outcomes from pilot projects and adapted savings-linked conditional cash transfer programs in some countries. To ensure successful program design and implementation, governments interested in savings-linked conditional cash transfers should make sure to fully assess the political, economic, regulatory, and infrastructural conditions present in their communities.

Exploring the potential of a conditional cash transfer intervention to reduce HIV risk among young women in Iringa, Tanzania

Cash transfer programs seek to alter structural determinants of HIV risk such as poverty and gender inequality. We sought to explore the feasibility and potential effectiveness of a cash transfer intervention for young women as part of combination HIV prevention in Iringa, Tanzania. Qualitative, in-depth interviews were conducted with 116 stakeholders and residents from the region, including key informants, service delivery users, and members of key populations. Most respondents felt a cash transfer program would assist young women in Iringa to have more control over sexual decision-making and reduce poverty-driven transactional sex. Respondents were divided on who should receive funds: young women themselves, their parents/guardians, or community leaders. Cash amounts and suggested target groups varied, and several respondents suggested providing microcredit or small business capital instead of cash. Potential concerns included jealousy, dependency, and corruption. However, most respondents felt that some intervention was needed to address underlying poverty driving some sexual risk behavior. A cash transfer program could fill this role, ultimately reducing HIV, sexually transmitted infections, and unintended pregnancies. As increased attention is given to economic and structural interventions for HIV prevention, local input and knowledge should be considered in a program design.

The short‐term impacts of a schooling conditional cash transfer program on the sexual behavior of young women

Recent evidence suggests that conditional cash transfer (CCT) programs for schooling are effective in raising school enrollment and attendance. However, there is also reason to believe that such programs can affect other outcomes, such as the sexual behavior of their young beneficiaries. Zomba Cash Transfer Program is a randomized ongoing CCT intervention targeting young women in Malawi that provides incentives (in the form of school fees and cash transfers) to current schoolgirls and recent dropouts to stay in or return to school. An average offer of US$10/month conditional on satisfactory school attendance - plus direct payment of secondary school fees - led to significant declines in early marriage, teenage pregnancy, and self-reported sexual activity among program beneficiaries after just one year of program implementation. For program beneficiaries who were out of school at baseline, the probability of getting married and becoming pregnant declined by more than 40 and 30%, respectively. In addition, the incidence of the onset of sexual activity was 38% lower among all program beneficiaries than the control group. Overall, these results suggest that CCT programs not only serve as useful tools for improving school attendance but may also reduce sexual activity, teen pregnancy, and early marriage.

Conditional cash transfers and health: unpacking the causal chain

This paper investigates whether conditional cash transfer (CCT) programmes that include health and nutrition components improve health and nutritional outcomes, and if so, which components of the programmes, or combination thereof, are important in achieving these improvements. Using evidence from Latin America, Africa, Asia and the Middle East, the paper adopts a theory-based approach that spells out the assumptions behind the expectation that the CCT interventions will have a measurable impact on health and nutrition outcomes. CCT impact evaluations provide unambiguous evidence that financial incentives work to increase utilisation of those key health services by the poor upon which the cash transfer is conditioned, if the beneficiaries have knowledge of this condition. However, results are mixed with respect to nutrition and health outcomes, suggesting that encouraging utilisation when the pertinence of services is unknown or of poor quality may not produce the expected effects. Incipient results from Mexico indicate, however, that service quality is not necessarily exogenous to the programme, but may be positively affected by giving the poor women skills, information, and social support to negotiate better care from healthcare providers. Findings from Mexico indicate that there are direct routes by which the cash transfers affect health, outside of the health sector interactions. In particular, the poverty alleviation achieved with the cash transfers may affect the mental health of beneficiaries, as well as their lifestyle choices. The main policy recommendation that ensues from this review is the need to find the right mix of incentives and regulation to improve the quality of care, while at the same time investing in the empowerment of users. Future research that explores the relative cost-effectiveness of investing in the supply versus the demand-side within the health system will be crucial, along with further research on the need for conditionalities. Other areas that could benefit from further evidence include morbidity outcomes from programmes other than Oportunidades, including mental health and chronic disease, impacts on health-related behaviours and attitudes, and how these factors affect outcomes, and the effects on out-of-pocket expenditure.

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<h3>Background</h3> Understanding the mechanisms underlying health behaviors is crucial to optimize interventions to improve HIV-related outcomes. Temporal discounting (TD), the tendency to discount the value of future rewards relative to rewards received closer to the present, may lead to risky health behaviors. Conditional cash transfer (CCT) interventions were developed in part to mitigate these effects. Despite this, few studies assess the direct role of TD on the effect of CCT interventions on HIV treatment and prevention. <h3>Methods</h3> Using data from a randomized controlled trial among 433 HIV-infected pregnant women in the Democratic Republic of Congo, we assessed three outcomes:1) retention to HIV care, 2) uptake of services for the prevention of mother-to-child transmission (PMTCT), and 3) viral suppression at 6 weeks postpartum. We used a delay discounting task to measure TD at baseline. We hypothesized that if CCT works by mitigating the harmful effects of TD, we would observe a positive interactive effect on the additive scale between high TD and CCT. We specified linear binomial regression models to calculate the individual and joint effects of CCT and TD, and we calculated the interaction contrast (IC) to illustrate possible interaction between these effects. <h3>Results</h3> The effect of CCT on uptake of PMTCT services was greater among women exhibiting high TD. The IC suggested a positive interactive effect between TD and the CCT intervention on uptake of PMTCT services (IC: 0.17; 95% CI: -0.15, 0.48). We observed no evidence of additive interaction between TD and the CCT intervention on retention or viral suppression. <h3>Conclusion</h3> This CCT intervention may help mitigate the harmful effects of TD on uptake of PMTCT services, though this mechanism did not appear to play a role for retention or viral suppression. Alternative approaches could be developed to address the effects of TD on HIV-related outcomes. <h3>Disclosure</h3> No significant relationships.